NURTURING CARE HANDBOOK

Strategic action 3

Strengthen
services

How to build systems,

improve the workforce, and
provide three-level support
NURTURING CARE HANDBOOK

Strategic action 3

Strengthen
services

How to build systems,

improve the workforce, and
provide three-level support
Nurturing care handbook. Strategic action 3: strengthen services. How to build systems, improve the workforce
and provide three-level support
(Nurturing care handbook. Start here: how to use the handbook, understand nurturing care and take action
– Strategic action 1: lead and invest. How to do governance, planning and financing – Strategic action 2: focus
on families and communities. How to listen to families, encourage communities and use the media – Strategic
action 3: strengthen services. How to build systems, improve the workforce and provide three-level support
– Strategic action 4: monitor progress. How to monitor populations, implementation and individual children’s
development – Strategic action 5: scale up and innovate. How to expand programmes, engage with the private
sector and use digital solutions)
ISBN (WHO) 978-92-4-005847-7 (electronic version)
ISBN (WHO) 978-92-4-005848-4 (print version)
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 Contents

Overview iv

Acknowledgements v

Using this handbook 1

Understanding Strengthen services 2

What is this strategic action? 2
What will this strategic action enable me to do? 3

Systems 4
Suggested actions 4
Overcoming the barriers 7

Workforce 8
Suggested actions 9
Overcoming the barriers 11

Three-level support 12
The three levels of support that families need 12
The twin-track approach 13
Suggested actions – universal support 14
Suggested actions – targeted support 18
Examples of targeted services for different groups 18
Suggested actions –indicated support 22
Overcoming the barriers 24

Signs that you are making progress 25

References. Tools, case studies and

further reading 26

S T R AT EG I C AC T I O N 3 iii
Overview

This handbook is composed of 6 guides. Each of the

five strategic actions of the Nurturing care framework
has a guide dedicated to it, and the Start here guide
provides a general orientation to the handbook.

Users may read all, or parts of the handbook,
depending on their needs. It is recommended
to read Start here before going to any of the
other guides.
The handbook is meant to be a living document
with guidance and resources that will be regularly
updated as more experiences are gained in the
implementation of the Nurturing care framework.
The use of this handbook is supported by the
nurturing care website, a vibrant portal with
country experiences, thematic briefs, tools, news
items, and expert voices. Always consult the
nurturing care website for new information that
can be relevant to the issues that you like
to address.
The Nurturing care handbook is available
at https://nurturing-care.org/handbook

F O R M O R E I N F O R M AT I O N

nurturing-care.org

C O N TA C T

NurturingCare@who.int
iv NURTURING CARE HANDBOOK
Acknowledgements

The development of this handbook was led by the World

Health Organization (WHO).

WHO is grateful to all those who contributed.
WHO also expresses gratitude to the authors
of the Lancet series Advancing early childhood
development: from science to scale (2017) who lay
the foundation for the Nurturing care framework
that underpins this handbook. A special word
of thanks goes to colleagues at the Institute for
Life Course Health Research at Stellenbosch
University in South Africa, for their support in the
development of this handbook.
This handbook is part of a set of resources for
implementing the Nurturing care framework.
Partners continue to collaborate in global
working groups to expand this set, facilitated by
staff at WHO, UNICEF, the World Bank Group,
the Partnership for Maternal, Newborn, and
Child Health (PMNCH) and the Early Childhood
Development Action Network (ECDAN).
WHO is grateful for the financial support provided
by the Children’s Investment Fund Foundation and
the King Baudouin Foundation USA that made the
development of the handbook possible.

Writing team:
Bernadette Daelmans, WHO; Kelly
Gemmell, Institute for Life Course Health
Research, Stellenbosch University;
Sheila Manji, WHO; Bettina Schwethelm,
consultant; Mark Tomlinson, Institute
for Life Course Health Research,
Stellenbosch University; and School
of Nursing and Midwifery, Queens
University, Belfast, United Kingdom of
Great Britain and Northern Ireland.
Content sections were provided by:
Betzabe Butron Riveros, WHO; Kate
Doyle, Promundo; Joanna Drazdzewska,
Women and Children First UK; llgi
Ertem, Ankara University; Jane Fisher,
Monash University; Svetlana Drivdale,
PATH; Matthew Frey, PATH; Liana Ghent,
International Step by Step Association;
Margaret Greene, Promundo; Patrick
Hoffmann, Human Safety Net; Robert
Hughes, London School of Hygiene and
Tropical Medicine; Dan Irvine, World
Vision; Romilla Karnati, MOMENTUM
Country and Global Leadership, Save
the Children; Vibha Krishnamurthy,
Ummeed Child Development Center;
Joan Lombardi, Early Opportunities;
Rajesh Mehta, WHO; Ana Nieto, UNICEF;
Katie Murphy, International Rescue
Committee; Frank Oberklaid, The Royal
Children’s Hospital Melbourne and the
Murdoch Children’s Research Institute;
Rafael Perez-Escamilla, Yale University;
Linda Richter, University of the
Witwatersrand; Mikey Rosato, Women
and Children First UK; Sofia Segura-
Pérez, Hispanic Health Council; Sweta
Shah, Aga Khan Foundation; Kate Strong,
WHO; Melanie Swan, Plan International;
Zorica Trikic, International Step by Step
Association; Francesca Vezzini, Human
Safety Net; Cathryn Wood, Development
Media International.
Additional contributions were made by:
Jamela Al-raiby, WHO; Judi Aubel,
Grandmother Project; Frances Mary
Beaton-Day, World Bank Group; Claudia
Cappa, UNICEF; Vanessa Cavallera,
WHO; Terrell Carter, American Academy
of Pediatrics; Elga Filipa De Castro,
UNICEF; Lucie Cluver, University of
Oxford; Tom Davis, World Vision;
Teshome Desta, WHO; Anne Detjen,
UNICEF; Amanda Devercelli, World
Bank Group; Erinna Dia, UNICEF;
Tarun Dua, WHO; Leslie Elder, World
Bank Group; Maya Elliott, UNICEF;
Ghassan Issa, Arab Network for Early
Childhood Development; Aleksandra
Jovic, UNICEF; Boniface Kakhobwe,
UNICEF; Masahiro Kato, UNICEF;
Jamie Lachman, University of Oxford;
Christina Laurenzi, Institute for Life
Course Health Research, Stellenbosch
University; Jane Lucas; Susanne Martin
Herz, American Academy of Pediatrics;
Colleen Murray, UNICEF; Daniel Page,
Institute for Life Course Health Research,
Stellenbosch University; Kiran Patel,
American Academy of Pediatrics;
Janna Patterson, American Academy
of Pediatrics; Nicole Petrowski, UNICEF;
Annie Portela, WHO; Chemba Raghavan,
UNICEF; Nigel Rollins, WHO; Chiara
Servili, WHO; Megan Song McHenry,
American Academy of Pediatrics;
Giorgio Tamburlini, Centro per la Salute
del Bambino Onlus; Juana Willumsen,
WHO; Shekufeh Zonji, ECDAN.
Participants in the meeting Innovating
for early childhood development:
what have we learned to strengthen
programming for nurturing care, held
13 – 14 June 2019 in Geneva, Switzerland,
all contributed to the content of this
handbook.
The following representatives provided
feedback on behalf of the Child
Health Task Force: Catherine Clarence,
Zacharia Crosser, Kasungami Dyness,
Olamide Folorunso, Kate Gilroy, Debra
Jackson, Lily Kak, Senait Kebede,
Allisyn Moran, Sita Strother, Lara Vaz
and Steve Wall.

S T R AT EG I C AC T I O N 3 v
Photo credit: © UNICEF/UN0205720/Njiokiktjien VII Photo
vi NURTURING CARE HANDBOOK
Using this handbook S T R AT E G I C A C T I O N S

1
This is part of the Nurturing care handbook, a practical
guide to using the Nurturing care framework to improve
early childhood development.
If you have not already, you will probably find it helpful
to take a quick look at the first part of the handbook:
Start here. This explains in more detail how the handbook
works, what nurturing care is, and how to get started.

2
It also includes practical advice on working in programme
cycles, engaging all stakeholders, and doing advocacy.
After Start here, the handbook is divided into five
strategic actions, each explained in a separate guide:

1 Lead and invest

2 Focus on families and their communities
3 Strengthen services
4 Monitor progress
5 Scale up and innovate
3
You can find out more and download the rest of the
handbook at https://nurturing-care.org/handbook

SCALE UP AND
INNOVATE *

S T R AT EG I C AC T I O N 3 * P r e v i o u s l y c a l l e d U s e d a ta 1
a n d i nn o v a te.
Understanding
Strengthen services
What is this strategic action?
This is about improving the services for
young children and their families, with health
and nutrition services playing a pivotal role.
It is about making sure that all caregivers and
young children receive support for providing
nurturing care, and that those with additional
needs get extra support and services.
2 NURTURING CARE HANDBOOK
Health and nutrition services already contribute to
nurturing care. Among much else, they provide care
before, during, and after birth, promote breastfeeding
and good nutrition, monitor growth, and prevent and
treat common childhood illnesses. It is important
to remember that all this is already in place and
needs to continue. But there will always be a need to
strengthen services wherever there are gaps – when
services have poor coverage or quality. And then there
are interventions that need to be added, to address
any missing components of nurturing care – most
often to support responsive caregiving, early learning,
safety and security, or caregivers’ mental health.
To achieve this balance of remembering,
strengthening and adding, programme planners and
managers need a shared vision of nurturing care,
across every sector and at every level, from national to
local. Standards, regulations, intervention packages
and coordination are needed to build strong services
that can meet the needs of young children, especially
the most vulnerable. Central to this is the workforce,
who need the right training, supervision, support and
motivation. Besides making sure staff have the right
skills, this also means upgrading the way services are
organized and coordinated.
Information systems are also essential. These track the
quality and coverage of every intervention and service,
and make leaders accountable to the community.
Funding needs to be adequate for all this work, and
the activities must reinforce each other. And all of this
needs to be governed by a family-centred approach,
to increase the reach of services, and families’ demand
for them and satisfaction with them.
The process of strengthening services can be
nationally led, sparked by local work, or initiated by a
particular sector. We generally recommend starting
small, so that activities can be adapted, fine-tuned
and made acceptable, before being made feasible for
scale-up to cover the whole country.
U nderstanding S trengthen ser v ices

What will this strategic action What follows is a collection of suggestions and advice,
based on our experts’ knowledge of what has worked
enable me to do? in countries around the world. As the age group
in focus is pregnancy to age three, the majority of
The Nurturing care framework describes five this guide offers suggestions on how to strengthen
outputs for this strategic action: services within the health sector. However, many of
• I dentify opportunities for strengthening existing the suggested actions would be applicable to an older
services in a range of sectors. age group as well as to other sectors.
• U
 pdate national standards and service packages
The suggested actions listed in this guide are intended
to reflect all components of nurturing care and
to support local action and decision-making. In each
the different levels of support needed by children
context, stakeholders will need to determine together
and their families.
the order and priority of actions to be completed for
• U
 pdate the workforce’s competency profiles and this strategic action as well as the five strategic actions
strengthen its capacity. as a whole.
• E
 nsure quality by providing mentorship and
supervision for trained staff.
• S
 trengthen monitoring of children’s development,
with timely referrals when needed. R E L E VA N T A U D I E N C E S

The suggested actions for Strategic action 3.

Although there are five outputs, we found it is
most helpful to support the work required by
looking at three areas:
Strengthen services have been developed with
the following stakeholder groups in mind:
• n
 ational and district programme managers
and supervisors;

Systems
How to strengthen mechanisms
behind the scenes – such as
policies, training, referral pathways
and coordination – to ensure that
improvements in services will
be effective.
• m
 anagers and faculty at educational
institutions;
• local and international implementation partners;
• funders, including the private sector;
• researchers and programme evaluators.

Workforce

How to give frontline workers the

knowledge and skills they need –
both for providing the services
and for training and supervising
colleagues – and create motivating
working conditions.

Three-level support

How to provide three levels of

support, depending on children’s
and families’ needs, from universal
support that benefits everyone, to
targeted or indicated support for
those with additional needs. 

S T R AT EG I C AC T I O N 3 3
Systems
Making changes to a service also means
changing the systems that support it.
For example, changes to a well-child
visit – perhaps to add in developmental
monitoring and counselling – would also
require changes in the health system.
These changes would include training,
supervision, referral pathways, the allocation
of staff time, and coordination with other
services. If the changes are big enough,
national standards and regulations will also
need to be revised. So, when introducing
a new service, think about the larger
implications for systems. Otherwise,
the change may be difficult to sustain.
4 NURTURING CARE HANDBOOK
Suggested actions
Start small, learn and adapt
People often think that supporting caregivers to
provide nurturing care should begin with national
early childhood development policies and grand
plans. In fact, starting small can be very effective.
Using demonstration sites allows you to build up an
approach that you can use as a model. This may take
longer, but it will be worth it, allowing you to learn
lessons that will help when scaling up to cover the
whole country. We will elaborate on this in the guide to
Strategic action 5.
Develop a cohesive vision for
implementation
Services are provided by many sectors, including
health, education, child and social protection,
agriculture and the environment. Think about the role
that each can play in supporting the families of young
children. Look at data on the quality of care and assess
whether children receive the essential interventions
necessary for healthy growth and development.
These include exclusive breastfeeding in the first six
months, immunization, and growth monitoring and
counselling, but also a safe home environment free
from violence and environmental toxins. Also look
at the way in which services are provided, specially
for children with additional needs and their families,
and examine whether there is good coordination
and a seamless continuum of care. Agree with
planners, frontline workers, specialists and community
members on the services needed to enable caregivers’
to provide their children nurturing care.
Be clear about the population you
plan to serve
Because resources are limited, it is important to
decide who should receive the planned services.
All families and children benefit from ensuring
children receive nurturing care, but some need it
much more than others. Carefully assess how you can
strengthen services that reach the entire population,
while also ensuring that those who need it most (e.g.,
vulnerable children, children with developmental
delays or disabilities have access to targeted support
or specialized care.
S ystems
I M P R O V I N G W E L L- C H I L D C O N S U LTAT I O N S
IN MOZ AMBIQUE
Since 2014, PATH has been working closely
with the government on well-baby
consultations in Mozambique, supporting
capacity building for counselling on responsive
caregiving and early learning, accompanied
by developmental monitoring.
PATH’s first step was to observe consultations
and get answers to some questions.
What usually happens? How long does the
consultation last? Is counselling part of the
consultation? Who gets counselling? What aids
– such as guidance cards, posters and manuals
– are used? What information does the provider
record, and where does it go?
The results showed that well-child consultations
were usually only 2 to 3 minutes long, that
there were no registers to record them, and
that counselling was only given if children had
obvious problems with health or nutrition.
PATH’s detailed analysis enabled it to work with
the government on a series of interventions to
improve well-child consultations. This resulted
in revised norms, updated registers, an updated
training curriculum for nurses, and new posters.
Frontline workers developed their capacity for
developmental monitoring, and counselling,
and play materials and learning sessions
were introduced in waiting rooms.
You can find resources such as manuals,
posters, counselling cards and evaluation
tools on PATH’s webpage, Nurturing care for
ECD materials (1).
And you can find the full case study
Mozambique: Harnessing Global Financing
Facility and World Bank funding to promote
nurturing care (2), showing how advocacy for
investments nurturing care led Mozambique’s
health ministry to integrate early learning
and responsive caregiving into its nutrition
intervention package, and mobilize resources
for its implementation.
S T R AT EG I C AC T I O N 3
Decide on interventions and how
to deliver them
As well as deciding which interventions to introduce,
you need to consider how to deliver them. Look at
what contacts young children’s families have with
services. Identify common touch points and decide
how to strengthen them, remembering that there
are different levels of support. There is more on this
later, in the section on Three-level support. The box on
community-based delivery platforms illustrates the
place of home visits and group sessions.
C O M M U N I T Y- B A S E D D E L I V E R Y P L AT F O R M S
Primary health care services provide important
touch points for addressing all components
of nurturing care. Home visits and group
sessions are complementary avenues to
support families of young children. Deciding
whether to deliver services through home
visits, group sessions or both depends on
intended outcomes you seek to achieve and
practical considerations (3). Studies have shown
that group sessions are as effective, or in some
instances even more effective, than home
visits. Group sessions are generally less costly
than home visits, they can influence group
norms, and allow for peer support. On the
other hand, sometimes attendance in group
sessions can be inconsistent. Home visits allow
for individualized assessment of the family’s
situation and tailored support. Irrespective of
the model, the intensity, frequency, and fidelity
with which the interventions are delivered are
critical for improving caregiving practices and
achieving outcomes.
To learn more, read about the studies
conducted in India and Kenya (4,5).
Design the activities
It is important to allow time – usually a few months –
to design your activities. This involves reviewing
available information, formulating questions and
talking to the community, as well as setting priorities
and testing them for acceptability, feasibility
and effectiveness. The box Improving well-child
consultations in Mozambique illustrates some of
the steps that were taken to strengthen services.
5
S ystems
Interventions should address local values, beliefs
and practices. That often includes identifying which
words the community uses, as well as tackling harmful
practices and making sure recommendations for home
care practices are appropriate. Make sure to involve local
communities – including providers and beneficiaries of
the interventions – in adapting them. This is described in
greater detail in the guide to Strategic action 2. Focus on
families and their communities.
TOOL
Adapting interventions for local use
To learn about simple, structured
methodologies to adapt the interventions
you have selected, have a look at WHO’s IMCI
adaptation guide (6) (IMCI is the integrated
management of childhood illness), as well as the
manual, What are the options? Using formative
research to adapt global recommendations on
HIV and infant feeding to the local context (7).
If you are asking more of frontline
workers, improve their support systems
When aiming to improve frontline workers’
performance, make sure you have everything in
place to support that – such as supplies, training,
supervision, incentives and the right referral pathways
(see box How a pilot study changed home visiting in
Kazakhstan). Think about workloads and how work
is organized. Those providing services cannot do
more unless they get more support, and giving
them more support means changing many
different parts of the system.
Monitor – it is the only way to improve
When resources are scarce, it is easy to think that
adding a monitoring component is too expensive.
But monitoring is always worthwhile. Even when
interventions are well supported by evidence, they
might not work when they are transplanted to a
different setting. If that happens, looking at the data is
a good way to find out what has gone wrong and fix it.
6 NURTURING CARE HANDBOOK
You need good records of what you have done and
what is being achieved. That includes monitoring
inputs (such as money and frontline workers’ time),
outputs (such as home visits and what they covered)
and outcomes (such as the coverage of the essential
interventions and home care practices). When getting
started, conduct regular (perhaps quarterly) reviews
involving the entire implementation team. This will
allow you to spot the problems, test solutions, and
gradually improve how interventions are delivered.
H OW A PI LOT S T U DY C H A N G E D H O M E
V I S I T I N G I N K A Z A K H S TA N
Piloting home visiting services in a remote
region of Kazakhstan have led to changes
across the country. Home-visiting nurses are
now expected to attend to all components
of nurturing care during pregnancy and the
first years of a child’s life. Services also address
maternal wellbeing, fathers’ engagement, and
child safety. The principle is to provide a basic
service to all, and additional support to families
that need more.
During the initial phase, the country team
adapted the UNICEF-ISSA home visitor resource
modules (8) that cover all components of
nurturing care. They also developed family-
centred tools that are now an essential part of
these nurses’ training – both pre- and in-service
– in universities and continuing education
colleges across Kazakhstan.
As a result, a regional IMCI centre became
a centre of excellence for training and
implementing this approach locally, as well as
for providing continuous education, both in
the region and in other parts of the country.
To find out more, read the full case study on
home visiting in Kazakhstan (9).
Use what you have learned in order to
advocate for scaling up
Your practical experiences of implementation on a
smaller scale can be used to demonstrate that the
approaches are feasible, user-friendly and effective.
That will help you to generate interest among policy
and decision-makers and advocate for more investment,
at national and local levels. It also enables you to be
better informed when coordinating action with other
stakeholders. For a practical example, read the box
Learning to scale up family participatory care in India.
S ystems
Partnerships
Partnership between caregivers and care providers
is essential for meeting the individualized needs of
children and families over a one size fits all approach.
Help care providers to work with parents, rather than for
them. This is well illustrated in the case study from India
in which parents are empowered to become part of the
team that cares for their very small small or sick babies
in an intensive care unit. To learn more about infant and
family-centered developmental care, ready the thematic
brief Nurturing care for every newborn (10).
L E A R N I N G T O S C A L E U P F A M I LY
PA R T I C I PAT O R Y C A R E I N I N D I A
In 2008, the Ram Manohar Lohia hospital
began to involve parents in caring for their sick
or small newborn babies. Over time, the special
newborn care unit developed ways of making
the caregivers part of the medical team, and
of providing training for them as well as for
the staff. The hospital had to balance babies’
medical needs with their need for responsive
care and parental support. And it supported
the parents in gradually taking on more of the
routine care for their babies – who were often
tiny – in the newborn care unit until they were
confident enough to provide all care after
discharge. One of the biggest challenges was
changing the staff’s attitudes, so that they saw
parents as valuable partners in providing care –
good quality and developmentally appropriate
– for these vulnerable babies.
The project proved that family participatory care
works and has many benefits – for babies, families,
staff and hospitals, even in resource-constrained
settings. Based on this experience, India has
developed national technical guidance and has
scaled up family participatory care for small and
sick newborns in many other parts of the country.
For more details, read the case study on Family
participatory care in India (11); the article Family-
centered care for newborns: from pilot
implementation to national scale up in India
(12); and the national operational guidelines
Family participatory care for improving
newborn health (13).
S T R AT EG I C AC T I O N 3
Overcoming the barriers
Forgetting there is a system
When designing an intervention, planners often pay
so much attention to content and skills that they do
not see anything else. When strengthening services,
think about how frontline workers are recruited and
supervised, what motivates them to stay, how data
on services’ quality and coverage are collected and
used, and how different systems provide services –
for example health and social services – must work
together to achieve results for families. This broader
programmatic support to the systems involved is
essential for expanding and sustaining
the services.
Fragmentation of care
Improvements at one level of the system might not be
matched by improvements at other levels. This makes
referral pathways less effective, and has a harmful
effect on the quality and continuity of care. Efforts
to provide universal support should not take place
in isolation. They should be complemented from the
start with investment in additional services that can
provide targeted support or specialized care to those
children and families who need it.
Lack of shared accountability
Joined-up action is hampered if it is not built around
accountability for shared outcomes. Make sure that
indicators, measurement methodologies and regular
review processes are well defined from the beginning,
and that monitoring activities are implemented as
planned. Multistakeholder collaboration works better
when organizations plan and monitor together, but
implement by sector.
7
Workforce
The early childhood workforce is vast and
varied. The frontline workers who deliver
services to young children and their families
include professionals, paraprofessionals and
volunteers, as well as the people who train,
supervise and support them. They come
from sectors including health, nutrition, child
care, early education, sanitation, hygiene,
housing, and social and child protection.
And they belong to many different types
of organizations – including public sector,
private sector, civil society, professional
associations and development partners.
8 NURTURING CARE HANDBOOK
Frontline workers are a diverse group of people
who give practical help - modelling, counselling,
coaching and information, all based on evidence.
They are also there to provide empathetic support for
struggling parents and other caregivers. A lot is asked
of them when many are affected by poor working
conditions and low status. And the necessary skills
and practices are not adequately covered in their
training, either before they begin their careers
or while they are working. Yet, many rise to the
challenge and do their jobs well, often under
difficult circumstances.
To do their jobs well, the frontline workers need a
great deal of support. That includes:
• t he right regulatory environment and standards
for service delivery;
• o
 pportunities to develop their technical knowledge,
skills and attitudes;
• s upport from managers and supervisors, such as
mentoring and supervision;
• e
 quipment, transport, and incentives – meaning pay,
but also the intrinsic reward of being able to do a
good job, and being recognized for it;
• t he way work is coordinated between frontline
workers and their colleagues at other levels of the
system, in their own sector and beyond.
All these factors determine the quality of services and
the ability of frontline workers to support caregivers to
provide nurturing care.
Workforce
Suggested actions
Assess current workforce policies
and practices
It is important to know what is there and what is
missing. List the people working on the front line
who can support families to provide nurturing care.
Review their current practices. Then look at the
policies that are in place to support their work. What
are the provisions for recruitment, training, continuous
professional development, mentoring and support?
Understanding policies and current practices better
will help you to see where action is needed to improve
working conditions, and plan.
Take a multipronged approach to
upgrading the workforce
Once you have assessed policies and practices, plan
how to develop capacities of different provider groups.
Engage with institutions and stakeholders to agree
the competences each group needs. Set standards for
quality of care and improve in-service training material,
develop short courses, and promote specializations and
lifelong learning, both online and in person. Upgrading
pre-service training is essential to create a workforce
that better supports families over the coming years.
The opportunity to do this may not be available
immediately, because curricula are usually revised every
few years, so it is important to be aware when the next
cycle of updating will commence (see box Upgrading
competences and standards for useful resources).
A useful resource to support all this work is UNICEF and
WHO’s practice guide (see the box).
TOOL
Nurturing care practice guide: strengthening
nurturing care through health and nutrition
services (14)
Developed by UNICEF and WHO, this guide is
for managers of health and nutrition services,
whether public, private or NGO managers. It is for
those who are interested in integrating support
for nurturing care into their services, but have
difficulty knowing where to begin. This guide
supports their efforts to develop integrated and
strengthened services that promote nurturing
care for the child’s optimal health, growth
and development. It includes examples of
interventions that frontline workers can try, as
they serve families and their young children.
S T R AT EG I C AC T I O N 3
TOOL
Upgrading competences and standards
“Competence” or “competency” usually means a
person’s measurable characteristics – including
knowledge, abilities, skills, experience and
behaviour – that relate to how well they perform
their work.
Defining the competences required for
a job can make training and professional
development programmes more relevant
to workers’ needs. This can also help with
continuous improvement, by enabling workers
and their supervisors to assess performance
more effectively.
A good way to define competences is to look
at evidence-based guidelines and standards for
quality of care. Examples of what these might
look like are the WHO’s guideline Improving
early childhood development (15), and the
WHO’s Standards for improving the quality
of care for children and young adolescents in
health facilities (16).
For more on this subject, see the Early
Childhood Workforce Initiative’s Strengthening
and supporting the early childhood workforce:
competences and standards (17).
Use adult learning methods to build skills
Professional education often does not give enough
attention to skills such as counselling, coaching,
empathy, and dealing with stigma and discrimination.
These are difficult skills to acquire. To increase
competence in these areas, use adult-learning
methods that are participatory, interactive and hands-
on, and give people plenty of opportunity to practice.
Frontline workers can get guidance on how to engage
with caregivers and young children from tools such
as WHO and UNICEF’s Care for child development
package. ISSA and UNICEF’s resource package for
home visitors also includes modules on adult learning
methods and supportive supervision. (See the boxes
for more on both these tools.)
9
Workforce

Improve the workforce’s conditions

when strengthening services
TOOL
Creating enabling environments and strengthening
services that promote nurturing care can be a big
Care for child development
undertaking. Counselling caregivers to provide
The WHO/UNICEF Care for child development nurturing care should not simply be a set of additional
(18) package provides guidance to help tasks for the workforce, as their workloads tend to
caregivers build stronger relationships with be large and their pay is often comparatively low. It
young children and solve challenges in providing is better to take the opportunity to look again at who
nurturing care. Central to the intervention is a does what and how. For example, by making small
set of age- and developmentally-appropriate changes to the organization of work in health facilities,
recommendations on play and communication client flows can be improved, and new activities
that guide counsellors in helping caregivers integrated, such as learning sessions in the waiting
interact with their children. The counselling aims room. Where community health workers (CHWs)
to increase the time parents spend with their are part of the system, they can make an important
children, and improve the quality of interactions contribution by doing home visits and facilitating
that affect learning and health. group sessions in the community.
In some countries, CHWs also work part-time in
Another useful package is Caring for the
health facilities and share tasks such as weighing,
child’s healthy growth and development (19).
triage and health promotion. Of course, issues like
Its materials are derived from Care for child
remuneration and overall recognition of the workforce
development, and guide frontline workers in
also need attention.
supporting caregivers on feeding infants and
young children responsively, giving care for child
development, preventing illness, and seeking Provide supportive supervision
care at the right time. and mentoring
Frontline workers are vulnerable to burnout, as
supporting diverse and vulnerable families requires
a demanding combination of empathy – in providing
services also in a nurturing way for the caregiver --
and technical competence. Supervision, along with
TOOL
mentoring by managers and peers, helps frontline
workers deal with their own stresses and feelings,
Resource package for home visitors keeping them effective and motivated. The Home
Visiting Workforce Needs Assessment Tool (described
The International Step by Step Association (ISSA)
in the Barriers section) encourages dialogue between
collaborated with UNICEF’s Europe and Central
managers and frontline workers to discover their
Asia regional office to develop Supporting
needs and find solutions together.
families for nurturing care: resource modules
for home visitors (8). Its modules aim to increase
the workforce’s awareness of the importance of
holistic child development, as well as improving
their knowledge and skills in delivering child-
and family-centred services. The package helps
frontline workers to reflect on their attitudes
to families, and to take a strengths-based
approach to engaging with them, inclusively and
respectfully, with all their different needs and
challenges. The materials appeal to providers
in many different roles, including physicians,
social workers and educators. They are living and
evolving documents, which can be translated
and adapted to the country’s local context.

10 NURTURING CARE HANDBOOK

Workforce

Overcoming the barriers Common expectations are needed in order to ensure

Lack of knowledge about the workforce
There is often not enough data about where frontline
workers are, what training they have and what
conditions they work under. And a significant number
of frontline workers may not be counted because they
are working in the informal sector. Invest in gathering
data about the workforce, as good information is
essential for change.
Lack of shared expectations
Analysis by the Early Childhood Workforce Initiative
(ECWI) (20) found that there is no common set of
expectations about what people working in education,
health, and social protection should know and be
able to do. In many cases, supporting caregivers to
provide nurturing care is not considered part of their
scope of work, and each sector and service still focuses
only on the nurturing care components that are close
to their traditional or usual roles.
attention is given to all nurturing care components
in workforce policies and regulations. Achieving
this requires political will, technical leadership and
coordination, at every level of government.
Building teams
Unless all providers who are meant to function
as a team receive similar training, new practices
can be difficult to implement, and results can be
disappointing. For example, doctors might not receive
training on responsive caregiving, while nurses
and community health workers do. This can lead to
conflicting advice, or to doctors failing to respond
properly to alerts raised by frontline workers about
a family or an individual child’s development.
So always think about the workforce as a team,
and train relevant groups together.
The Early Childhood Workforce Initiative brings
together ideas and resources in this area, including
its Home visiting needs assessment tool (see the box).

TOOL

ECWI’s needs-assessment tool for the Pr

og
home-visiting workforce nt
ra
e

m
The Home visiting workforce needs assessment
m

De
Curricula,
on

Workforce
tool (21) was developed by the Early Childhood Materials,
sig
vir

Expectations
and Resources
Workforce Initiative. The tool aims to help
En

n
ministries and government agencies to support
Enabling

people delivering home-visiting programmes

for pregnant mothers and caregivers with
Home
children under 3. Inspired by UNICEF’s Visitors Training,
Pre-primary subsector analysis (22), it Workforce Supervision,
is aimed at countries with regional or national Conditions and Career
Development
home-visiting programmes, and is organized
around seven topics. It guides the discussion
of high-level policy-makers, planners and
supervisors with frontline workers about e
a nc
their ideas, needs and expectations to make M ur
on ss
ito yA
ring
changes in standards and working conditions -- A n d Q u a li t
ultimately affecting the way services are shaped
and delivered to families ensuring nurturing
care for caregivers and their children.

S T R AT EG I C AC T I O N 3 11
Three-level support
The three levels of support that
families need
The Nurturing care framework sets out
three levels of support, depending on
caregivers’ and communities’ needs.
The brief explanations below are taken from
Start here, the first part of this handbook.
12 NURTURING CARE HANDBOOK
Universal support
This is for everyone, provided through the services
that families of young children use most. It is
designed to benefit all families, caregivers and
children in a country or district, regardless of their
risk or financial means.
Information and resources are tailored to the child’s
age and the family’s circumstances. When there are
problems, universal support identifies them early and
refers caregivers and children to the right service. And
it gives guidance in times of change, such as when
mothers return to work, or when day care is needed.
Targeted support
This focuses on people or communities who are
affected by risks such as poverty, undernutrition,
adolescent pregnancy, HIV, violence, displacement
and humanitarian emergencies. Children with
disabilities and their families are also at risk of
exclusion. The aim is to reduce the damaging effects
of stress and deprivation,
and strengthen individuals’ capacity to cope.
These families and caregivers still need access to
universal support. But they also need extra help from
trained providers (professional or non-professional),
whether in facilities, their community, or at home.
They may also need extra resources, such as financial
benefits. And they need continuous assessment to
spot when they are ready to stop getting targeted
support – or to move on to more specialized,
indicated support.
Indicated support
This provides specialized services for families or
children with additional needs, including young
children without caregivers, or those living with
depressed mothers or in violent homes. It also
includes children whose birthweight was very low,
or who have disabilities, developmental difficulties
or severe malnutrition.
Introducing each of these three levels of support
requires different actions, so we will look at them
one at a time. But first, a word about how the
different levels work together.
T hree- le v el support
The twin-track approach
This is a useful way of thinking about how the different
levels can work together, when approaching children
with additional needs. Should those children be
supported by mainstream services or specialized
ones? The twin-track approach is to answer, “Both”.
The first track is universal services, which need to
include children with additional needs. Frontline
workers need training so they can recognize where
every family and child is, from the most typical to
those with the most risk factors – and identify those
risk factors as early as possible.
Frontline workers will care for all children, and will
also know about the specialist services provided by
the second track. They then help the family get the
support they need and coordinate with the services
involved. The child is never shunted off onto the
second track, away from the first, but always
remains on both.
This helps to avoid several problems. It means there
is no stark line between children who use universal
services and children who need additional support.
It makes spotting and dealing with developmental
risks and difficulties a standard part of supporting
any child and any caregiver. And it means already-
overwhelmed families do not have to deal with the
task of accessing and coordinating different services
for a child who has additional needs (see the boxes
on this page).
NURTURING CARE FOR CHILDREN WITH
D E V E L O P M E N TA L D I S A B I L I T I E S
In 2016, an estimated 52.9 million children below
5 years of age experienced a developmental
disability, including epilepsy, intellectual disability,
hearing loss, vision loss, autism spectrum disorder,
or attention deficit hyperactivity disorder (25).
Most children lived in low- and middle-income
countries where access to services was limited. While
in many countries prevalence had been going down
since 2010, increases in the numbers of children
affected were observed in countries in sub-Saharan
Africa, the Middle East and North Africa (24).
Children who have a developmental disability
need nurturing care just as much, or even more,
as other children. They have dreams, capacities
S T R AT EG I C AC T I O N 3
A P P LY I N G T H E T W I N -T R A C K A P P R O A C H
IN MUMBAI
The twin-track approach has been successfully
put into practice by the Ummeed Child
Development Centre in Mumbai, India. Its Early
Childhood Development and Disability (ECDD)
programme (23) trains community health
workers (CHWs).
These CHWs use Care for child development
(18) principles to promote the development of
all children. Using a simplified version of the
Guide for Monitoring Child Development (24),
they monitor children up to the age of 3, so they
can identify, as early as possible, any risk factors
and delays in development.
As well as supporting all families with young
children, the CHWs identify local resources
to address any risk factors for early child
development that families may face, as well as
services for children with disabilities. The CHWs
also act as advocates for these children and
their families, making sure they are included
in community activities.
Some CHWs then do a one-year certificate
programme to become child development
aides. This extra training means they can
directly provide services for children with
developmental difficulties.
and aspirations. These can be realized, provided
the child and the family receive timely and
adequate support. Frontline workers can play a
critical role in early identification of these children,
provide counselling and practical support, and
facilitate referral for more specialized care. They can
coordinate between different services and ensure
that different providers work as a team with the
family and the child.
In most countries, substantive investments are
needed to strengthen specialized services for
children with disabilities, alongside efforts to
strengthen universal support for nurturing care.
To learn more, read the forthcoming publications:
WHO/UNICEF global report on children with
developmental disabilities (26) and the thematic
brief (27).
13
T hree- le v el support
Suggested actions –
universal support
These are the actions we suggest for the
first of the three levels of support: universal,
which is designed to benefit all children,
caregivers and families.
Assess the current universal package
Take stock of what universal services are currently
offered to families of young children. Assess how each
contact made with primary care services is used to
enhance caregivers’ knowledge and abilities to provide
their children with nurturing care. Then identify which
interventions might be missing, and what it would
take to add them, in terms of resources, training, and
other changes. This is sometimes referred to as a top-
up approach. The box Examples of contacts to use for
universal support might be helpful (on the next page).
Add missing components of nurturing
care to your services
When you are upgrading services to add missing
components of nurturing care, you can adapt
proven material rather than developing your own
from scratch. For example, UNICEF and WHO’s
forthcoming Strengthening nurturing care through
health and nutrition services will provide guidance
for updating facilities and services. The box Nutrition
support and rehabilitation services provides
examples of additional tools.
14 NURTURING CARE HANDBOOK
TOOL
Nutrition support and rehabilitation services
Infant and young child feeding and child
nutrition are core to ensuring children receive
adequate nutrition, a component of nurturing
care. Not only is adequate nutrition essential
for young children to grow and be healthy,
early initiation and exclusive breastfeeding,
and responsive feeding, also enable the
caregiver and the child to develop a close and
loving relationship. Responsive feeding is a
part of responsive caregiving and is essential
to adequate nutrition. The child needs both
to thrive. The WHO guideline Improving early
childhood development (15) recommends that
support for responsive care and early learning
should be included as part of interventions for
optimal nutrition of infants and young children.
The Caring for the child’s healthy growth
and development (19) package is composed
of counselling cards and training manuals to
support counselling on infant and young child
feeding, care for child development, prevention
of illness and timely care-seeking. It is suitable
for use by a range of frontline workers including
community health workers.
The Advancing Nutrition project has developed
counselling cards with a specific focus on
responsive caregiving and opportunities for
early learning. These have been designed
specifically for integration into nutrition services.
The cards fit seamlessly with the UNICEF
community-based infant and young child
feeding materials (28).
T hree- le v el support
E X A M P L E S O F C O N TA C T S T O U S E F O R
UNIVERSAL SUPPORT
These are some examples of caregiver’s contacts
with primary care services that are usually part
of universal support. Those services have a basic
aim (marked “basic”) and can be enhanced with
interventions to support more components
of nurturing care (marked “to be added”). The
additional services are listed the first time they
are relevant, but most could also be provided in
any of the later contacts.
Antenatal visits
Basic: promoting healthy lifestyles, preparing
the mother for changes ahead, supporting birth
planning, and counselling on danger signs in
pregnancy.
To be added: explaining nurturing care, assessing
the parents’ mood and any potential for violence,
and engaging with fathers to prepare them for
parenthood and help them support their partner.
Birth and postnatal care
Basic: supporting early and exclusive breastfeeding
and skin-to-skin contact, spotting signs of illness or
malnutrition, and rooming-in.
To be added: counselling on how to respond to the
baby’s cues, supporting bonding with the baby,
and engaging fathers in caring for and interacting
with the baby.
Immunization
Basic: getting the right vaccinations at the right
time.
To be added: helping the caregiver in soothing
the child and dealing with their own fear of
vaccinations, assessing and advising on the baby’s
health and growth, observing how caregivers
interact with the baby, modelling responsive
caregiving, addressing caregivers’ physical and
mental health, and providing guidance and toys
in the waiting area.
S T R AT EG I C AC T I O N 3
Well-child visits
Basic: advising on feeding – including responsive
feeding – as well as preventing illness, care-
seeking, micronutrient supplements, and
monitoring growth and development.
To be added: asking about concerns over health,
development and behaviour, discussing positive
discipline and how to prevent injuries, offering
information about parenting groups, addressing
caregivers’ physical and mental health.
Sick-child visits
Basic: treating the illness, advising caregivers on
managing it and on continued feeding, referring
children with danger signs.
To be added: scheduling follow-up visits (including
for growth and development monitoring and
counselling), identifying and referring children
at risk of suboptimal development, making all
sick-child visits family-friendly.
Growth monitoring and counselling
Basic: counselling on feeding tailored to the
child’s age, detecting signs of faltering growth
or becoming overweight.
To be added: assessing the family’s risks,
monitoring the child’s development, counselling
on responsive caregiving, early learning activities,
safety and security, identifying and referring
children at risk of suboptimal development.
Childcare centres
Basic: providing responsive care, modelling good
hygiene practices, providing nutritious food in the
right amounts, playing and communication in an
age-appropriate way.
To be added: conducting parenting sessions,
counselling caregivers on nurturing care,
monitoring children’s development, providing
information about other community resources,
referring to health and social protection services.
Birth registration office
Basic: registering the baby’s birth.
To be added: providing information about
nurturing care and about services offering
parenting and other support.
15
T hree- le v el support
Integrate care for caregivers
Caregiver’s physical and mental health influences their
ability to care for their child. Therefore, services should
pay attention to both the child and their caregiver.
Women who are pregnant or caring for young children
have greater emotional needs, and intense and long-
lasting emotions sometimes limit what they can do
in their daily lives. In low-income countries, 20–33%
are affected by depression or anxiety, with perinatal
psychosis found in 1 woman per 1000, according to
a Lancet article (29). The proportion is always higher
when life circumstances are especially difficult,
because of poverty, humanitarian emergencies, or
gender-based restrictions.
Caregivers who are experiencing mental health problems
can be less able to concentrate, plan and organize. They
can also have less motivation, feel less able to engage
with other people, find it harder to make decisions, and
care for their own health and well-being. Their capacity
for caregiving will also be significantly affected.
FRONTLINE WORKERS’ AND C AREGIVERS’
M E N TA L H E A LT H
Untreated perinatal mental health issues come at
a tremendous cost to society, as a London School
of Economics and Political Science report (30)
shows. The most common mental health problems
associated with childbearing are depression, anxiety,
and persistent low mood and sadness. Parents
of small and sick infants are especially likely to
experience perinatal mental health issues.
Pregnant women and mothers suffering from these
problems are less likely to care for themselves, and
find it more difficult to respond to the baby’s needs,
and to care with warmth and affection. This affects
the child’s health, development and well-being.
For men, childbirth and the transition to fatherhood
can also trigger mental health problems. And
“mother-centric” health services often miss fathers,
even though they are directly involved in supporting
the mother and baby.
Countries – including the United Kingdom, Australia,
the USA, Kazakhstan and Serbia – are increasingly
recognizing the impact mental well-being has on
parenting capacity and outcomes for children. They
are responding by monitoring the mental well-being
of pregnant women, new mothers and sometimes
fathers, during the contact they have with them in
primary health care and home visits.
The evidence shows that, with limited additional
training, non-specialist frontline workers can identify
caregivers who are at risk, and support the vast
majority of them in the community or in primary
health care.
16 NURTURING CARE HANDBOOK
Universal services should monitor caregivers’ well-being
routinely, as good outcomes for children depend on
caregivers getting the psychosocial support they need.
It is natural that the well-being, mental health and general
functioning of the primary caregiver – often the mother
– has a significant influence on a child’s development.
After all, this is the person with whom young children
often spend much of their time. And when caregivers
experience depression or excessive anxiety, they and their
children are at risk of many negative outcomes, including
social isolation and economic deprivation.
All women benefit from support and encouragement
– whether from their families, health workers, or people
in their local communities. They need to experience
these people as interested (in their pregnancy or the
baby), kind and uncritical, and helpful, whether with
information or practical assistance. Empathy helps and
blaming does not. Getting the right support protects
women’s mental health (see the box Frontline workers’
and caregivers’ mental health).
Women appreciate being asked how they are
doing emotionally by frontline workers whom they
experience as being kind and trustworthy. Although
women may not want to be asked about their
mental health in front of other people – including
family members – they are more likely to talk in a
private space where they cannot be overheard.
To identify mothers who are at risk, frontline
workers can ask two simple questions:
• “ During the past month, have you often been
bothered by feeling down, depressed or
hopeless?”
• “ During the past month, have you often
been bothered by little interest or pleasure
in doing things?”
If the mother agrees with either of these, then a
follow-up question can open the door to further
discussion: “Is this something you would like help
with?” Other evidence-based tools, such as the
Edinburgh Postnatal Depression Scale, can also be
used in conversation to get mothers (and fathers) to
talk about their mood.
If frontline workers have training in basic empathic
listening skills and cognitive behavioural therapy
techniques, they can then give simple, helpful
suggestions. These include engaging in physical
activity, focusing on the relationship with the baby,
and making sure they have good enough nutrition,
sleep and relaxation. (See the Three tools box for
more practical suggestions.)
T hree- le v el support

Make sure frontline workers can identify

TOOL
Three tools to help with caring for caregivers
There are several evidence-based, scalable
interventions for supporting caregivers’ mental
health.
WHO’s Thinking healthy guide (31) is the most
notable. It is a targeted group approach, focusing
on listening with empathy, family engagement,
problem solving and guided discovery.
UNICEF’s Caring for the caregiver (32)
package aims to build frontline workers’ skills
in strengths-based counselling to increase
parents’ and caregivers’ confidence and help
them develop stress management, self-care and
conflict-resolution skills.
Another helpful resource is UNICEF and ISSA’s
Supporting families for nurturing care: resource
modules for home visitors (8) – a tool described
in the Workforce section of this guide.
For more information on programme
approaches to help caregivers deal with mental
health issues, consult the global community of
mental health innovators website.
who needs more support
Strengthen frontline workers’ capacity for monitoring
individual children’s development and well-being.
For this, they need to pay attention not only to the
child, but also to what is going on in the family
and community. This is discussed in more detail
in the guide to Strategic action 4, in the section
on monitoring children’s development. Here we
call attention to the home-based record, a health
document used to record the history of health services
received by an individual. It is kept in the household
and complements the records maintained by health
facilities. The use of a home-based record in the care
of pregnant women, mothers, newborns and children
has shown to improve care-seeking behaviours, male
involvement and support in the household, maternal
and child home care practices, infant and child
feeding, and communication between health care
providers and caregivers. For more information, read
the guideline WHO recommendations on home-based
records for maternal, newborn and child health (34).
Ask caregivers for regular feedback
on services
Caregivers’ feedback is helpful for continuously
improving services’ effectiveness, reach and
engagement. Plan ways to engage with caregivers,
including fathers, to discuss their experiences of the
services and hear their suggestions for improvements.

C O V I D - 1 9 PA N D E M I C A N D
P S YC H O S O C I A L S U PP O R T

The COVID-19 pandemic has been putting

enormous strain on parents and other
caregivers. This has affected their mental health
and their ability to provide nurturing care for
their children. Community health workers also
have been affected. All have been coping with
many stressors, including loss of income, food
insecurity, and rising domestic violence. Learn
more about how to provide mental health and
psychosocial support to community health
workers, parents, and other caregivers in a case
study from India (33).

S T R AT EG I C AC T I O N 3 17
T hree- le v el support
Suggested actions –
targeted support
These are the actions we suggest for
the second of the three levels of support:
targeted, which is for those who need
extra help because of factors such as
poverty, undernutrition, adolescent
pregnancy, HIV, violence, displacement
and humanitarian emergencies.
Examples of targeted services
for different groups
Children at risk of malnutrition
Counsel caregivers on feeding, food and
micro-nutrient supplements, as well as on
responsive caregiving and age-appropriate,
play-based early learning. Attend to parents’
mental health, and link to peer-support
networks. Follow up regularly.
Children affected by HIV
Ensure continuity of services for the caregiver and
the child. Prevent mothers transmitting HIV to
their children. Counsel caregivers on responsive
caregiving and age-appropriate, play-based early
learning. Attend to parents’ health and their
emotional and social well-being.
Young mothers
Support the mother in making the transition to
parenthood, and help her to build a relationship
with her baby. Assess her home situation and the
support she can get from other adults. Link to other
services – to complete her education, for example,
or sustain a regular income.
18 NURTURING CARE HANDBOOK
Carefully evaluate who to target
Targeted approaches are designed to create
additional contacts and provide tailored support
for vulnerable families (see the box for examples).
As they are more intensive, be careful when deciding
who to target, particularly when resources are limited.
When indicated services are also needed, make them
easy to access. And work with caregivers to make
the best use of universal services to overcome any
stigma or social exclusion.
Children in humanitarian settings
Provide aid in terms of shelter, medical help and
nutrition, and combine this with a concern for
safety (such as safe spaces and play corners).
Support parents’ health and their emotional and
social well-being, including stress reduction and
dealing with post-traumatic stress symptoms
(PTSS). Counsel them on responsive caregiving
and early learning.
Families living in poverty
Optimize the use of household assets. Counsel
caregivers on home-care practices, including using
all the resources that are available to communicate
and play with the child. Provide information about,
and facilitate access to available services and
benefits. Help families make good use of benefits,
such as cash transfers, to improve care for young
children.
T hree- le v el support
Involve caregivers in designing the services
Find out what prevents caregivers and families from
providing nurturing care. If they are not accessing
services, find out what is preventing them. Use
participatory approaches to design the interventions
so that caregivers feel they own the process and the
outcomes.
The brief Nurturing care for children affected by HIV
(See the box) illustrates how universal and targeted
services, such as home visits or group sessions, can
help them.
NURTURING CARE FOR CHILDREN
AFFEC TED BY HIV
Of the world’s children aged five or younger, 5.4
million are exposed to HIV but not infected, and
530 000 have the virus. Better services mean
that more mothers with HIV are surviving, as
are their babies – 1.3 million of them each year.
The challenge now is to ensure that these
children not only remain HIV-free but also
develop optimally. By identifying, protecting and
supporting caregivers and families, through a
combination of universal and targeted services,
caregivers can be better supported to provide
their children nurturing care.
For more on how to strengthen routine services
and provide targeted support, read the brief,
Nurturing care for children affected by HIV (35).
Decide how to deliver targeted
interventions
Choose how to deliver targeted interventions –
whether in home visits, group sessions, extra contact
with health services, or at childcare centres. A
mixture is likely to be most effective. There are several
well-tested packages, sometimes called parenting
programmes, that can be used to give caregivers
greater support. Think about adapting one of these
packages, as that can make it easier to decide on
the interventions, delivery approaches, and timing
of contacts. (See the boxes on Timed and Targeted
Counselling and Reach Up.)
S T R AT EG I C AC T I O N 3
W H AT I S A PA R E N T I N G P R O G R A M M E ?
A parenting programme is a structured
intervention directed at parents or other
caregivers. It can target the general population,
or just populations in need or at risk.
Programmes can focus on many things,
including reducing maltreatment of children,
reducing harsh or punitive parenting by
improving positive parenting, or reducing
children’s behaviour problems.
Programmes can be run at home, in a centre,
or online, and can serve or groups. They
normally consist of a structured series of
sessions, using a range of learning activities,
and often follow a manual. Many group
programmes also strengthen the caregivers’
peer support network.
Do not compromise on interventions’ dose,
duration or intensity
When resources are limited, it is easy to compromise
on things like frontline workers’ training, how long
the intervention lasts, or the service’s quality. But
those compromises can mean the intervention fails to
achieve results. A narrative review (3), looked at several
NGO-led, community-based programmes in east and
southern Africa, combined with a global literature
review. This showed what makes interventions in
targeted services most effective.
It suggests interventions need to combine the
right amounts of:
• p
 articipation – intended beneficiaries attend at
least 70% of sessions;
• d
 uration – a minimum of 6 months for home visiting,
but preferably 12 months;
• intensity – home visits and parenting sessions of 1–2
hours, every two weeks or more often.
19
T hree- le v el support
TOOL
Timed and Targeted Counselling (TTC) – a
targeted support package
World Vision’s Timed and Targeted Counselling
(TTC) is an approach that has now been
implemented in 38 countries. It uses interactive
storytelling to deliver messages at the right
time to families with young children – especially
those who are most vulnerable
and marginalized.
TTC aims to change behaviour essential for
children’s health and development. Frontline
workers (professionals or volunteers) visit
families four times during pregnancy, three
times in the week after birth, and then six times
in the next two years. It includes the whole
family and emphasizes the father’s contribution.
Evaluations in 10 countries have shown
consistent improvements in home care, health
and nutrition.
To find out more, read Timed and Targeted
Counselling (TTC): a service package
of the CHW project model (36).
20 NURTURING CARE HANDBOOK
TOOL
The Reach Up programme – another targeted
support package
The Reach Up programme is another approach
that has been adapted for many different
settings, from rural Jamaica to Bangladesh.
It can be managed by home visitors or facility
staff, and is also used with families who are
refugees or impoverished.
The curriculum and materials help caregivers
and children to engage together in play,
learning, and mutually rewarding relationships,
setting the stage for learning and achievement.
It has been integrated with health, nutrition and
social protection programmes in 15 countries
and proved effective in improving children’s
development, with the effects sustained in
adulthood. The evaluations of the programme
include an article in The Lancet (37), and a paper
in Science (38).
To support parents during the COVID-19
pandemic, Reach Up has developed a new
parent manual (39) with activities for children
up to the age of 3.
To find out more about the package, visit
the Reach Up programme’s website (40).
T hree- le v el support
Avoid a deficit approach
In situations where people face many social
disadvantages, stress and insecurity, it is tempting to
see only problems to be fixed. But all communities
have hidden strengths, networks and sources of
resilience that can be found and built on. Taking a
respectful and fully participatory approach empowers
participants to be more active in shaping and
contributing to interventions. See the box for an
example of using Roma health mediators.
U S I N G M E D I AT O R S T O R E A C H
V U L N E R A B L E R O M A P O P U L AT I O N S
IN SERBIA
The Roma are among the most excluded
groups in Europe, facing discrimination and
many social disadvantages – including poor
access to services.
Serbia’s ministry of health is working to
overcome this by employing Roma health
mediators to accompany nurses on home visits
in Roma settlements. The mediators recognize
and respond to Roma families’ health and
social needs, help them access mainstream
health services, and give tailored parenting
information and education.
To find out more, read UNICEF’s more
detailed case study, Roma health mediators:
connecting communities (41).
S T R AT EG I C AC T I O N 3
Remember that needs are diverse
Families vary in the amount of support they need.
This is particularly true for humanitarian situations
and displaced populations, with some families
needing only limited assistance while others require
intensive support, especially when they are affected
by significant trauma as well as basic health and
survival issues. To get a much better understanding
of what help they need, always involve community
leaders and members in planning, implementing and
monitoring the activities. See the box Nurturing care
in humanitarian settings for examples of programmes
and suggested actions.
N U R T U R I N G C A R E I N H U M A N I TA R I A N
SETTINGS
In humanitarian settings, infants and
young children face huge challenges in
surviving, let alone thriving. In 2018, 29 million
children were born into areas affected by
conflict, according to a UNICEF press release (42).
These children will grow up with the trauma
of displacement and war. But those who get
nurturing care will heal more quickly and are
more likely to reach their full human potential.
Which interventions are most effective depends
on the length and type of emergency.
The International Rescue Committee (IRC)
designs and delivers quality early childhood
programmes in crisis and conflict settings. These
include programmes for children, such as Play
and Learning Spaces, and Preschool Healing
Classroom. The IRC also works in partnership
with Sesame Workshop on the Ahlan Simsim
(43) programme, which integrates high-quality,
mass-media edutainment.
There are also programmes that focus on
families and caregivers, including home visiting,
group sessions, and key messages that are
integrated with other services. IRC’s website
also has a report on how it used interactive
digital messaging through WhatsApp
in Syria (44).
For details of simple actions to take at different
phases, see the brief Nurturing care for
children living in in humanitarian settings (45).
21
T hree- le v el support
Suggested actions –
indicated support
These are the actions we suggest for
the third of the three levels of support:
indicated, which provides extra services and
help to those with greater needs, including
children with disabilities, developmental
difficulties or severe malnutrition.
Assess how to identify children with
additional needs
In many countries, children with additional needs
are only identified once they reach pre-school or
school age. This misses opportunities to promote
their development when their brains are most
malleable and leaves struggling families without
support. Their caregivers’ physical and mental health
may also need specialized support, which should be
offered by the same services that support children.
(There is more on caregivers’ mental health in the
section on universal support.)
Review frontline services’ tools for monitoring young
children’s development. This requires looking at risks
in the environment as well as at children’s individual
development. There are more details on this in the
guide to Strategic action 4, in the section
on monitoring children’s development.
Map services available in the community
Work with frontline workers and community
organizations to map the existing infrastructure,
services and networks that support children and
families who have additional needs. Also assess the
quality of these services. Look at factors such as
whether the neonatal intensive care unit includes the
family in the care of their small or sick baby, whether
mental health services are free of stigma, and whether
children with developmental delays or disabilities
can access services and participate in mainstream
activities such as child day care.
22 NURTURING CARE HANDBOOK
Assess the legal context, policies
and standards
Assess laws and policies that protect and support
families and children with additional needs. If they are
already in place, are they well implemented? These
laws and policies include disability rights and social
inclusion, the outlawing of corporal punishment,
statutory laws and regulations on dealing with child
maltreatment and domestic violence, and laws that
prohibit placing young children in residential care.
TOOL
The INSPIRE strategy to end
child maltreatment
Maltreatment of children is widespread,
and includes physical, sexual, emotional
and psychological abuse, as well as neglect.
According to WHO’s Global report on ending
violence against children (46), 50% of children
under the age of 19 have experienced some
form of abuse, often starting in early childhood.
The INSPIRE strategy (47) and its accompanying
handbook (48) recommend seven evidence-
based approaches to preventing and reducing
violence against children. They include
measures to modify unsafe environments by
means of physical, economic, social and cultural
changes, as well as adopting policies that
prohibit all forms of violence against children.
INSPIRE highlights the importance of creating
safe, sustainable and nurturing family
environments, in which there is support for
parenting. Frontline workers need to be able
to provide this support, and to help prevent
and manage child maltreatment. Parenting for
Lifelong Health (49) has been developed to help
with that. It is a suite of parenting programmes
– open access, non-commercial and rigorously
tested in a number of countries – for preventing
violence in low-resource settings. The material
is tailored for different age ranges, including
infants and toddlers.
T hree- le v el support

Build up service providers’ competence
Indicated needs can be complex and often require
approaches that span several disciplines. Frontline
providers and specialists need to be able to
collaborate so they can provide care that fits the
family and the child’s development. Evidence shows
that frontline workers can play an important role in
supporting caregivers here. There are tools to help
with that, including WHO’s Caregiver Skills Training
package (see the box) and the international Guide for
Monitoring Child Development (23) (GMCD – see the
guide to Strategic action 4).
Many countries need to improve their services’
capacity for early intervention, and to develop the
disciplines related to developmental paediatrics. Many
also need to build accessible multidisciplinary service
networks to support children with developmental
difficulties or disabilities – as well as their families.
Make services easy to access and use
Families of children with multiple needs benefit
from approaches that bring services together.
These families are often overwhelmed by the time
and effort required when there is no coordination
between services, and when each service must be
registered for separately.
Frontline workers can play an important role in
taking primary responsibility for the child and family.
They can find information to help with the child’s or
family’s difficulties by consulting written material or
talking to experts. They can open doors and work
across disciplines to help families access care. In early
intervention, the gold standard is transdisciplinary,
non-fragmented care in which frontline workers and
specialized staff work together in support of the
child and the family. This approach also helps to
save families from confusion and promotes the
cost-effective use of resources.

Engage with key stakeholders and develop

TOOL clear accountability mechanisms
To prepare a plan of special services with each
Caregiver skills training (CST) course family, involve those who already provide support
to these families. This includes the family’s primary
WHO’s Caregiver skills training course helps care providers (e.g., nurse, doctor, home visitor,
the families of children with developmental community health worker), civil society, and informal
difficulties. It combines group sessions with parent-support groups. This enables them to work
home visits, and is delivered by non-specialists, together better, and to be accountable for the desired
such as nurses, community workers and outcomes. Getting key stakeholders involved from
other providers. the start will help to make any new initiatives more
The course uses modelling and coaching to feasible and realistic.
help caregivers communicate better with
their children. The caregiver learns to read Make the right budget allocations
their child’s cues and respond appropriately,
Responding early to developmental difficulties or
strengthening the child’s adaptive behaviour
maltreatment reduces costs over the child’s lifetime.
and reducing the more challenging ways of
Allocate budgets on that basis: early.
acting. Caregivers also learn to set individualized
goals, solve problems, and establish routines at
home, using these as opportunities for learning,
development, and joint engagement.
CST is designed to improve daily living skills, the
relationship between caregiver and child, as well
as the child’s functioning – including their ability
to communicate and their social, emotional and
cognitive development. The course has been
found to increase caregivers’ self-confidence,
coping skills and psychological well-being, as
well as their knowledge and skills in parenting.
Find out more by visiting WHO’s webpage on
Caregiver Skills Training (50). The course is
available on request, by emailing mhgap-info@
who.int.
An online version of the training, called eCST, is
also available.

S T R AT EG I C AC T I O N 3 23
T hree- le v el support
Overcoming the barriers
Here are some of the important barriers
to improving the three levels of service –
universal, targeted and indicated.
Good intentions but limited investment
It takes time, effort and money to strengthen services
and build systems that can serve all families and
children according to their needs. Taking shortcuts
often leads to disappointment. The most common
are reducing training time, limiting the mentorship,
supervision, and support for frontline workers, or
failing to stick to quality standards (or fidelity) in
implementation. When designing the interventions,
be clear and precise, and then compromise as little as
possible when implementing them. It is better to do
less and to do it well, than to expand quickly and fail
to achieve results.
Lack of awareness and support in
the community
When the community is not aware of services and
there is no demand for them, efforts to strengthen
services may eventually slacken. To increase the
community’s support for services that promote
nurturing care and contribute to early childhood
development, link the efforts to an outcome that
the community values. That could be about all
children thriving and achieving, or moving towards
a fairer society, or it costing less in the long run to
provide good support early on.
Social exclusion and stigma
Communities, including frontline workers, can have
cultural myths and misconceptions about particular
people or conditions, such as childhood disabilities
or families with social disadvantages. Frontline
workers need to address this directly. They should give
good, accessible information to caregivers and the
community, and work respectfully with all families.
Better coordination is
made easier by adopting
a transdisciplinary
approach that puts
frontline workers in
the centre of the
care network.
24 NURTURING CARE HANDBOOK
Lack of early identification and
referral pathways
In many settings, it is still a challenge to identify,
early on, the children and families who need extra
support, and to intervene early. Although many
countries are stating that they are implementing early
childhood intervention (ECI) approaches, too many
children and families are still not reached, including
in these countries. There is more guidance on how to
approach this in the section on monitoring children’s
development, in the guide to Strategic action 4. It is
essential to identify developmental difficulties and
maltreatment early, and to have referral pathways
for addressing them. But these things will only be
possible if they are part of a comprehensive system
based on people’s rights.
Lack of coordination among services
Getting different services to work together is
essential for improving outcomes. Many families,
particularly those with children who have complex
needs, are overwhelmed by the difficulty of engaging
with lots of different services that do not join up.
Better coordination is made easier by adopting a
transdisciplinary approach that puts frontline workers
in the centre of the care network. Services need to be
organized around supporting daily life and the child’s
functioning. They need to do this through family-
centred, community-based early intervention, and in
accordance with the WHO International classification
of functioning, disability and health framework (51).
Being overwhelmed by emergencies
The COVID-19 pandemic has shown how quickly
services can become overstretched and unable to
sustain essential functions. This is especially serious
as stress and poverty increase, and access to services,
and use of them, falls. As a result, millions more
children are at risk of common childhood illness,
malnutrition, maltreatment, and lack of preventive and
curative treatment, as a Lancet article (52) has shown.
All this demonstrates the importance of building
a strong service network that is resilient to such
shocks. We must also build on the many innovations
– including digital technologies – that are now being
used to re-establish services. To find out more about
the options, see the online COVID-19 resources from
nurturing care (53) and ECDAN (54) websites.
Signs that you are
making progress
You can work on the activities in this
strategic action in many different ways,
and it is natural that progress in some
will be faster than others.
The aim is to build a continuum of services
that can support all families of young
children in providing nurturing care,
and identify and intervene early for those
children and families who need additional
support. This requires strengthening
primary care services, capacity development
for specialized care, and formation of
trans-disciplinary networks that can
team around the child and the family.
S T R AT EG I C AC T I O N 3
Strengthening services can be complex. These are
some signs of progress, and targets to aim for:
• C
 ounselling on nurturing care is included in families’
routine contacts with services, beginning in
pregnancy.
• D
 evelopmental monitoring is well integrated with
counselling, and considers the environment in which
the child is growing up.
• F
 or early childhood development, the population’s
risks have been defined and there are services for
reaching vulnerable groups with socially inclusive
approaches.
• T
 here is a continuum of care that covers different
disciplines and that offers universal, targeted and
indicated services. Services are available for families
and children with additional needs.
• P
 re-service training curricula have been updated
to address all components of nurturing care.
• I n-service training materials and job-aids have
been updated to address all components of
nurturing care.
• T
 here is a pool of master trainers and facilitators who
can conduct skills training and provide mentorship.
• T
 here are policies that protect and support the
workforce, so that they have decent conditions and
feel well supported.
• T
 here are data about the quality and coverage of
services that counsel caregivers on how to provide
their children nurturing care. There is also feedback
from the services’ clients. The data and feedback are
gathered, documented and used to improve quality.
• I n allocating resources, priority is given to
populations, families and children who are
most vulnerable.
25
References
Tools, case studies and
further reading
1. Tool: PATH’s materials for well-baby consultations
Primary Health Care. Nurturing care for ECD materials.
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primary-health-care/ecd-materials/, accessed 1 October
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2. Case study: Nurturing care in Mozambique
Karuskina-Drivdale S, Frey M, Picolo M, Manji S. Mozambique:
harnessing global financing facility and World Bank
funding to promote nurturing care. In: Nurturing Care for
Early Childhood Development. Geneva: Partnership for
Maternal, Newborn and Child Health; 2020 (https://nurturing-
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HIV burden countries
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narrative review. Vulnerable Children and Youth Studies.
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Grantham-Mcgregor S, Adya A, Attanasio O, Augsburg B,
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26 NURTURING CARE HANDBOOK
6. Tool: Adapting interventions for local use – IMCI guide
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What are the options? Using formative research to adapt
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Sudan P, Jhalani M, Gurnani V, Khera A, Prabhakar PK,
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Ministry of Health and Family Welfare; 2017 (http://nhm.gov.
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Nurturing care practice guide: strengthening nurturing care
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S T R AT EG I C AC T I O N 3
19. Tool: Caring for the child’s healthy growth and
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Caring for the child’s healthy growth and development.
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